Sexual Healing by Dr. Margarita Kressin

Because of what I do, people often open up to me and people ask sex questions. Recently, (let’s call her) Norma complained to me that it hurt to have sex (official medical term is dyspareunia). Nothing hurts any other time, but definitely with sex, there is pain.

How long has it been going on?

10 years.

10 years?! Why did you not get help?

I thought it was just part of getting older. (She is in her late 50s) Besides I didn’t think there was anything we can do for it. So I just dealt with it. But now it’s getting worse that we have had to stop since I was in tears.

Dyspareunia is a common condition and can actually happen at any age. It can be due to a multitude of factors from fibroids, STDs, vulvar issues or vulvodynia, vaginal dryness and atrophy, or muscles of the pelvic floor issues. An examination is necessary to rule out any life-threatening condition.

I told the patient to see her gynecologist to rule out any gynecologic pathology and if there is nothing they could find, and if she still has pain with sex, then I can certainly see her.

She was thankful that there could be a reason and a name to her condition. She was most relieved to find out that it was just “not in her head” and that it wasn’t because of her husband.

The lesson is that pain is never normal. Unfortunately there are cases where it can be the normal if this becomes a chronic pain condition. There are studies that show that if we can get to the patient soon after the pain starts (in this case — pelvic pain seen within a two-year onset) there is a greater chance of curing the patient compared to a patient who was seen after two years. So the second lesson is that the sooner you get your pain taken care of the better the chances that this gets cured.

Libido or sex drive in women is a difficult thing to paint plainly. There have been three sexual models that have been proposed to try to explain sexual function in women: the Linear Model, Basson’s circular model and Rosen’s biosociophysical model.
 
The linear model goes like this: We start with being sexual stimulated (visually or tactile), then get aroused which heightens. Then orgasm comes and then recovery. Few women, we think, respond this way. This fits more males and how they respond sexually.
 
The Basson model takes a neural women (neither aroused nor stimulated), but then arousal can come via foreplay, massage, etc. … then libido follows. We think more women respond this way than the linear model.
 
A good analogy to this theory is like going to the gym. Let’s face it, very few of us want to exercise (author included). But we get dressed, put on our shoes, drive to the gym or go outside and begin exercising. Whether we run, use the elliptical or treadmill, or use weights, in the beginning it is somewhat painful. And, at times, we try to talk our way out of it. Then the heart rate goes up. We start to feel good. We start sweating, get into a rhythm, and actually get into it. Sometimes you feel so good, you keep going, longer than what you had planned. Then the run ends, you're sweating, you feel good, the endorphins are going and then you say, "Wow, that was awesome! Why don’t I do this everyday?!" Sex is like this.

I tell my patients and their partners to not expect that the women will start initiating sex. But, sometimes, all it needs is a little foreplay, a little motivation. Help her get her sneakers on and put her on the treadmill. The goal is to enjoy it once the treadmill starts going, and for her to stay on it long enough to feel good.

Because of what I do, I am definitely pro-sex. But a caveat I should say is that this be done between consenting adults and be done safely. I went to a recent conference where there was a lecture on oral and throat cancers. In the past, oral and throat cancer’s greatest risk is smoking. However, recently there has been a change in the leading cause of this cancer. This was actually brought up in my colleague Dr. Bruce Campbell's blog, Reflections in a Head Mirror. He writes about the relationship of oral cancer and oral sex.

Some facts about Human Papilloma Virus (HPV):

• HPV – most common cause of cervical cancer, now also in vulvar cancer (50 percent of pre-cancerous lesions now seen in 20-39 years of age)
• HPV – now seen in 72 percent of oral tumors (D’Souza 2007)
• Smokers have a 3x increased risk
• Heavy alcohol use a 2.5x increased risk
• Greater than 6 oral partners an 8.6x increased risk
• HPV 6 and 11 are the strains that cause benign genital warts. HPV 16 and 18 cause 70 percent of cervical cancer
• 1,700 new cases of HPV-associated head and neck cancers are diagnosed in women and nearly 5,700 are diagnosed in men each year in the United States (Ryerson, 2008)

What caught the attention of the room is the statistic of having more than six oral partners increases your risk more than smoking. We do know that it has been reported that oral sex among teens is often viewed so casually that it needn't even occur within the confines of a relationship. A study published in 1999 in the Journal of the American Medical Association examines the definition of sex based on a 1991 random sample of 599 college students from 29 states. Sixty percent said oral-genital contact did not constitute having sex. And ...

• According to a Centers for Disease Control and Prevention survey, 28 percent of males age 15-17 reported giving oral sex to a female and 40 percent reported receiving oral sex from a female.
• Among females aged 15-17, 30 percent report giving oral sex to a male, and 38 percent report receiving oral sex from a male.
• Some teens reported having oral sex but not vaginal sex (13 percent of males and 11 percent of females aged 15-17).

Joe and his wife consider the choices they have. The easiest being the pills, the PDE-5 inhibitors — sildenafil, verdenafil, tadalafil (brand names: Viagra, Levitra, Cialis). Joe gets excited of the prospect of getting an erection. Then he paused and asked: How is my orgasm going to be?

I assured him that it will remain the same.

But how can it be, my erections will be affected, how can my orgasm stay the same?

Like many men out there, Joe doesn’t know that each sexual function actually is independent of itself. What that means is one can have an erection without orgasm (the sensation of sexual peak) or ejaculating (the actual muscle contraction of the pelvic floor of men) or emission (movement of semen outside of the penis). One can orgasm therefore without erection. In post-prostatectomy men (men who have had their prostate removed because of prostate cancer), there is orgasm and ejaculation but erection may not happen and they do not have emission because their seminal vesicle and prostate are gone. Spinal cord patients sometimes can’t have erection on command but they can orgasm but not ejaculate and may or may not have emission.

So I can still have an orgasm even if the penis isn’t very hard?

Absolutely! Let’s say you want to use other things; tongue, fingers, other senses — a practice called sensate focus, you can do this and still ejaculate without getting hard.

This piqued his wife’s interest because she, like Joe, is herself changing sexually and would like to explore more about their sensuality than just focus on the genitals.

I gave them the handout for sensate focus and our sex therapist’s contact. I gave a prescription for one of the PDE-5 inhibitors. They felt that it was good to hear that their intimacy could be preserved and that sex is more than the genitals. But also relieved that if Joe did want to use his penis he still has the option to do this.

After our determination that Joe (worth repeating here that all of my "patient" names and stories are made up) has erectile dysfunction, we then reviewed his medical history (he has mild blood pressure problems and pre-diabetes that is supposed to be diet controlled), surgical history (none), social history (used to smoke a pack per day, but quit 10 years ago). He is not following a diabetic diet and does not exercise. He does not take any medications.

We looked over to his wife and made sure that she is supportive and that she herself does not experience sexual issues. She thinks that their sexual relationship is very important and besides a slight decrease in libido she has no issues. She explains that once she and her husband get going, she does well.

We then focused on lifestyle changes for Joe, what he can do on his part to help his erectile function and prevent further deterioration. We then discussed all his options, from first line therapies (medications, intraurethral systems), second line therapies (injection, vacuum devices, surgeries). We discussed the pros and cons of each therapy, the side effects and possible complications (there is no free ride, no matter what we’d like to think, in medicine), and the benefits of one therapy versus another.

We outlined all of these and made certain recommendations depending on what he would use consistently, and something he and his wife can be comfortable with and incorporate into their sexual activity.

We also offered our sex therapist for sexual counseling (not marital counseling, a point that was important to make) to give them tips and educate them about their sensuality and sexuality. This could also potentially address other issues that we did not address from a medical standpoint. As I always point out — the brain is still the biggest sex organ (as much as Joe would like to think the penis is THE sex organ).

And I reminded them to be careful about what they see and hear in ads. Please do not use any herbal or supplement "medications" advertised on TV.  And yes, there are no guarantees. If there were, don't you think legitimate physicians would be using it already?

The biggest lesson Joe and his wife learned was that this was more about erectile dysfunction. It involved sexual health, a couple’s sexual function, and a myriad of therapies that he can choose from.